Treatment of Borderline Personality Disorder with the Application of Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is a form of Cognitive Behavioral Therapy developed by Marsha Linehan to treat symptoms of Borderline Personality Disorder (BPD) such as self harming behaviors, suicidal thoughts, emotional distress, impulsivity, and suicidal attempts. In order to apply the treatment approaches, it is important to understand the borderline personality disorder.

 BPD reveals instability in relationships, mood, and self image. People suffering from this disorder experience volatility in their attitudes and feelings toward other people over short periods of time. Their emotions are often erratic and they show a rapid shift in emotions and feelings, particularly   anger. They are also very unpredictable, argumentative, and impulsive and are known for their habits like gambling, spending, sex, eating sprees, and manipulation skills. It has been found that these individuals lack a clear and coherent sense of self and are often uncertain about their values, loyalties, and choice of careers. They are often indecisive and tend to have a series of brief and stormy relationships. They lack the capacity to evaluate others and are also subject to chronic feelings of depression and emptiness. These personalities are known to be manipulative and also experience a breakdown under emotional stress like the schizotypal personalities. They may also appear psychotic during times of stress. Many of them have been sexually or physically abused and have endured traumatic experiences.

 Originally the term borderline implied that the person is on the borderline between neurosis and schizophrenia but recent research does not support this concept. Pope and his coworkers found that borderline personalities also had either major depression or bipolar disorder. These people respond well to the usual somatic treatments for affective disorders. They also found that most of the BPD could also be diagnosed as having another personality disorder such as histrionic, narcissistic, or antisocial. There is a large overlap among the various personality disorders. BPD is more prevalent in women than men and it runs in the family. Heritability in BPD is about 68%. The three phenotypes for BPD are:

Affective: Readiness to become angry, anxious, or to shift between anxiety and depression.

Impulsive: Acts without thinking about the long term consequences; especially to act in self injurious ways like slashing wrist and inflicting pain to self to seek attention.

Interpersonal: Insecure attachments characterized by desire for closeness and fears of rejection or abandonment.

The prognosis is not very good and response to treatment is poor. Clearly much remains to be learned about this disorder. Most BPD clients are being treated in community. Over 70% of clients with BPD are in individual therapy and taking standing medications during all follow up periods.

DBT is a very effective treatment strategy designed by Marsha Linehan. DBT combines standard cognitive behavioral techniques for emotional regulation and reality testing with concepts of mindfulness, distress tolerance, and acceptance. The key elements of DBT are conventional behavior therapy and cognitive therapy, along with its concepts of dialectics and mindfulness. Dialectics is based on assumptions such as everything is connected to everything else, change is constant, and two opposites can be integrated to form a concept that is close to the truth. It tends to resolve the contradictions in two opposing views or ideas. Since BPDs tend to have polarized thinking and intense emotions, they are taught to have dialectical thinking as an alternative to extreme polarized thinking. Therapists try to teach the patients how to recognize multiple view points versus reacting to events as perfect or unbearable. Additionally, they use “both/and instead of ‘either/or approaches. This teaches them to stop the polarized and absolute thinking and help them look into healthy options to adopt as choices.

Therapists also try to focus on balancing the concepts of validation/acceptance and change/problem solving. This simply means that therapy sessions are focused on accepting the patient, being respectful of what he or she is saying, feeling and doing. Moreover, therapist also tries to assist the person regain confidence both by assuming that his or her behavior makes sense and treating the person as equal. This helps the patient use new coping skills and it also builds a life worth living.

DBT has four stages of treatment:

Stage 1: In this stage, the therapist tries to focus on stabilizing the client and achieving behavioral control. Therapist tries to target behaviors such as cutting, suicidal actions, manipulation, emotional distress, and impulsivity. It is important to note that there are certain behaviors that can interfere with therapy if the therapist is not careful and tactful. Behaviors that unbalance therapy include: extreme acceptance or change, extreme flexibility or rigidity, extreme nurturing or withholding and extreme vulnerability or irreverence. Also, it is important to note that therapy can become ineffective if the therapist is disrespectful to the client. At the same time, it is also important to know that there are certain behaviors of the client which can interfere with the effectiveness of therapy. For example, if the client is engaging in behaviors that burn out the therapists and push their limits. Borderline personality clients tend to have a very poor show rate and they are often uncooperative with treatment. They disagree with their therapists and fail to comply with treatment recommendations. Sometimes they become very demanding and rude to their therapists. They also like to shop for therapist and they tend to easily devaluate therapist even though in the beginning, they idolized them.

Stage 2: Many borderline personality disorder clients have experienced Post Traumatic Stress Disorder (PTSD). In this stage, the therapist tries to replace desperation with non traumatic emotional experiencing by addressing the PTSD symptoms.

Stage 3: In this stage, the therapist tries to focus on helping the client achieve “ordinary” happiness and unhappiness and reduce ongoing disorders and problems in living.

Stage 4: The focus is to resolve a sense of incompleteness and achieve pleasure and happiness, spiritual fulfillment, and connectedness with the external world.

It is also important to point out that there are four components of treatment of BPD:

1.      Individual therapy:

In this mode of treatment, therapist tries to review issues that occurred during the week. They also review the diary cards for targeted behaviors and work towards improving potential of the clients to use newly learned skills.

2.      DBT Group Therapy:

There are four group modules which are covered in the DBT group therapy. The two modules that focus on acceptance are Mindfulness and Distress Tolerance. The other two modules that focus on change are Emotional Regulation and Interpersonal Effectiveness.

3.      Phone Coaching:

 Therapist tries to offer a brief structured intervention with the client on phone for about 5-10 minutes to help the client come up with problem solving strategy and help use the DBT skills. This type of intervention helps reinforces the application of DBT skills in order to avoid self injurious behaviors and decrease impulsivity on the part of the clients. It also provides immediate positive reinforcement of more effective skills and behaviors.

 4.      DBT Consultation Group:

It is important for the therapist to participate in the consultation group to avoid burn out. This gives a chance to the therapist to hear the view point of others and get some objectivity in the approach.  Additionally, this also helps the therapist to stay balanced in his or her approach to the client, while supporting and praising the therapist for applying effective DBT interventions. It is very crucial to be a part of the DBT consultation group in order to meet the requirement of DBT treatment.

 Following are some of the skill training that is offered in the DBT groups:

MINDFULNESS:

Borderline personality Disorder folks are often impulsive and have difficulty controlling their impulses and emotions. They need to be more mindful in their approach so they are taught some mindfulness exercises. They are encouraged to observe the events and experiences without judging them. They are also taught to let go of the good and the bad, the fair and the unfair, the just and the unjust, wise and the foolish. Mindfulness requires full attention so it is very crucial to use the five senses of seeing, hearing, smelling, touching, and tasting in order to be mindful of one’s surroundings and experiential world. Focusing on the breath helps train the mind to become more mindful and it facilitates taking control of emotions and thoughts. It helps the clients avoid judging situations and most of all self. By practicing mindfulness, they learn to respond rather than react. Sometimes mindfulness decreases the intensity of certain emotions like anger, sadness, and envy. Clients are asked, for example, to put a raisin in their mouth and experience the taste before swallowing it. They are encouraged to chew it slowly, enjoy each bite of the raisin and become fully aware of its taste by using the sense of taste, sight, and touch. They are told that their minds are like Teflon coated pan and they are asked to discard extraneous thoughts from the mind and focus only on the experience. In this way they learn to stay in the present moment without worries about the past and future. It is like meditation which causes the calming effect and reduces the intensity of irritation, anxiety, depression, anger, and hostility.

 Emotional Regulation and Distress Tolerance

Clients are also taught to handle emotional distress by regulating their emotions and their interpersonal skills are also honed by giving them exercises and handling situations effectively. They are encouraged to use the wise mind rather than listening to the emotional mind. They are also taught Cognitive Behavioral skills like reframing their dysfunctional thought patterns with logical and reasonable counterstatements. DBT is encouraged to utilize skills leaned in the group sessions Distress tolerance skills assist the client to tolerate stress and utilize coping skills to manage stress and regulate emotions. Supportive therapy is used to assist client in identifying feelings and the cause of the feelings.

Interpersonal Effectiveness Training:

This helps improve the ability to relate to those in authority. Client tries to rebuild a relationship, for example, with mother that she has spoiled due to being impulsive and reactive. Clients learn to get along better with others with effective communication, assertive skills, and expression of feelings in an adequate manner. They also learn to get along better with the other group members and their network of friends. They are given exercises and home work assignments and these are reviewed by the therapist who also offers feedback to them.

       In this way, we see that one can change the mental status and become more rational and insightful with the help of DBT. The person can also improve his or her mood by working on negative emotions like anger, hostility, irritability, agitation, uncooperativeness and restlessness. They develop affect which is congruent to mood and as treatment progresses; their mood becomes euthymic versus depressed. They become more cooperative with the gradual use and application of the DBT skills taught in therapy. Moreover, they become more tolerant of the therapist and decrease their verbally abusive behaviors. Many clients with BPD become chemically dependent and also get in trouble with the law. However, with treatment, they are able to complete the chemical dependency treatment, comply with court and probation, and become able to make medical and dental appointments without being asked to leave due to their impulsivity and erratic behaviors. They begin to exercise control on their impulsivity and become more empathic to the needs of others versus always being absorbed in thoughts about self interest.

In conclusion, the research shows that DBT is the preferred treatment modality to treat Borderline Personality Disorder.
Hypnosis can also help people with borderline personality disorder reduce impulsivity with deepeners and mindfulness.Please visit our Blossom Hypnotherapy page to learn how hypnosis can help reduce symptoms of Anxiety disorders.